Attitudes towards the issue of the euthanasia, as well as policies on termination of life on request around the world, changed many times over the years. The recent changes and developments in health legislation in some countries resulted in a growing public discussion on the issue of euthanasia. Various events occurring in different places around the world played a key role in the growing publicity of the concept of euthanasia. The French Senate’s decision to approve the law allowing patients a right to terminate their life and the 2001 Termination of Life on Request and Assisted Suicide (Review Procedures) Act in the Netherlands became significant issues in the public debate, a subject of controversies, and a matter of active discussion in different media. There is a number of various perspectives from which the issue of euthanasia can be observed, including those of separate individuals who seek to resolve the pain of their own or their loved ones, societal attitude, the perspective of the ethical norms, as well as opinions of the medical professionals, and legal implications and norms.
This brief’s objective is to analyze the background of ethical, sociological, legal and criminological perspectives on euthanasia and various procedures of termination of life on request , to review and evaluate advantages and disadvantages over the years after the legalization of euthanasia, termination of life on request and assisted suicide policy in the Netherlands after its acceptation in 2001, to discuss the lessons that can be drawn from this experience for the further implementation in other countries; and to suggest the issues and aspect that require further debate and deeper analysis.
Background: arguments for and against euthanasia
In modern medical and legal discourse, euthanasia is understood as ending a patient’s life with the intention to spare suffering and pain (Griffiths et al. 2008). It is mostly applied in the cases of patients who are terminally ill, and euthanasia as a medical professionals’ practice is not legalised in the majority of countries. However, the discussion on the amount of rights of health care workers and the interests of the patients are a subject of the debate since the times of Francis Bacon, who defended his position by arguing that the roles of a doctor extend beyond curing to promoting sweet and easy death (Griffiths et al. 2008).
The debate on euthanasia has a long history that determines the context in which a certain policy is supposed to function. This context consists of the cultural nuances, ethical views and social norms developed over the years, and the experiences of the legal and criminological practice, existing advancements and procedures.
Hence, the first step to analyze the policy of the euthanasia and termination of life by the physician is to explore the background of the issue, the moral, social, legal and criminological context of its existence in general, and attitude and ethical norms towards it in the Netherlands in particular. The attitude towards the amount of rights medical professionals and the patients themselves have in deciding what is best for the latter changed depending on the epoch in question. Which is why, the paper is to examine not only the existing in modern society norms on the issue of euthanasia but also philosophical reflections, that can be used not only as the academic materials but as the ethical guidelines for the health legislation and medical care professionals.
Criteria for a due euthanasia: ethical, sociological, and legislative perspective
Implementation of any medical procedure has, in fact, the ethical and sociological context. For the policy of the health law to be successfully carried out in the form of a daily legal and medical practice, it needs to match with the existing moral value, ethical standards, social norms. The reflection on the termination of life and choice between life and death is part of the cultural background influencing both the norms and boundaries of legislation and ethical standards of medical professionals.
From the perspective of classical ethics in relation to the principles that can be applied in making policy on euthanasia, one of the most influential philosophers Immanuel Kant reflects on the ethical grounds of the action, including such action as euthanasia. He suggests that an activity is considered ethically right when it is performed for the purpose and with the respect of the obligation. For him, reasonable human being is somebody who manages his “will” and obligation with cause. What concerns the criteria definition for a certain health-related policy, Kant discusses the principle of definite necessities, according to which the action is ethically right if an individual wishes such action to be universalised. The philosopher also gives a lot of thought to the aspect of the human reason and consciousness, as opposed to other living creatures (Fletcher 2015). In such a way, he draws attention to the fact that human beings should not be just utilitalised. Thus, Kant would presumably oppose the practices of economic euthanasia, or the euthanasia for the patients whose illness is not terminate. Therefore, an individual choosing to terminate his or her life through euthanasia is using him or herself as a mere being and hence not regarding his or her reasonableness. From such a philosophy by Kant, only the voluntary euthanasia is ethically justifiable, and only in cases of the terminally ill individuals who decide to take his or her life with a sound mind. In such cases, the medical professional’s action would be rational and hence it the patient’s consent is considered an obligation.
Thus, Kant’s ethics draws three important elements of the context of the ethical policy on euthanasia. First of all, it is voluntary nature of the procedure, neither economical, nor any other external issues should force either a patient or a doctor into making a decision on euthanasia. The second important criterion for the euthanasia to be ethically justifiable, according to Kant, is the terminal character of the disease; otherwise, the action is considered as a mere criminal act. In particular, in the 2001 Termination of Life on Request and Assisted Suicide Act, it is stated that the euthanasia is only possible if the physician cannot provide any alternative ways of treatment considering the patient’s situation (Van der Heide et al. 2007). And most importantly, the criterion that found its reflection in all the legislative documents on the issue of the euthanasia is the sound mind of the person who makes a decision on the euthanizing. In modern circumstances, it is the decision of the medical professional together with the consent of the patient or his or her legal representative, or the initiative of the patient that meets all the criteria to be due.
When speaking from the standpoint of the sociological background of the issue, there are various schools of thoughts concerning utilitarian approach, as well as the social norms and values developed over the years that need to be accounted in the creating the policy. One of the most vivid and detailed considerations of the problem in this perspective was made by John Stuart Mill. Mill’s moral and ethical theory focuses on avoidance of pain or suffering and increasing pleasure. By him, activities are desirable in proportion as they are likely to bring happiness and wrong when they have the tendency of reducing happiness by introducing pain and suffering. Therefore, active voluntary euthanasia can bring pleasure or happiness for several individuals, and hence, the act is termed as right according to Mill’s theory. First of all, the individuals suffering from agony will be eased the pain and having power over their lives will create happiness. Moreover, the family members of the patient, who share the pain of their relative, and the ones who keep on spending huge amounts of money in the treatment will be freed of pain. Thus, utilitarian principles correlate with the humanistic social norms and moral values, dominating in the modern societies. The ground concepts from this point of view are the relief from the pain and suffering as a humanistic guideline, and as the important for the health-policy making criterion, that is reflected in the Dutch legislation on euthanasia.
Moreover, the due criteria for euthanasia in the 2001 Termination of Life on Request and Assisted Suicide Act stand in the due agreement with the Criminal Code, which creates the proper cohesive structure for the termination of life policies based on the principles of ethical values, social norms, and consistent laws.
Arguments against euthanasia: possible challenges for the policy
Most of the opponents also argue the some of the diagnosis by the doctors may be wrong. Therefore, this forces the patients to go through the process while his or her disease may be curable. For answering this claim, the proponents react by stating that there are few cases where such errors are made. However, this does not support the fact that euthanasia should be illegal. Therefore, it is legalised; the persons to make diagnosis would only be the eligible medical practitioners. Moreover, to reduce the error misdiagnosis, three doctors should discuss the diagnosis and conclude whether euthanasia is suitable or not suitable.
Some religions consider euthanasia as a sin arguing that it is only God who is the giver of life and it his choosing whether to take it or not dismissing the power of man take a life of another man. Also, attempting to commit suicide is also a sin and the case of euthanasia is not unique to that rule. Those who make the decisions of euthanasia are faced with a dilemma where the action is needed when religion is concerned. There are many views on euthanasia, and debate on euthanasia is not expected to end soon. Nevertheless, it is imperatively important to observe a case critically before dismissing or accepting any patient’s request.
The third argument by the opponents of euthanasia is concerning the options of employing new and advanced treatment to save lives of the terminally ill. Hence, they argue that new treatments techniques are available to save lives of such patients. Hence, in an instance of fatal illnesses, the medics will be regularly forced to come up with new options that are not readily available, and the chances of the patients dying are very high before new treatments are discovered.
However, there are considerable reasons that make the policy of the voluntary euthanasia ethically morally acceptable. Active voluntary euthanasia has objective benefits overruling the subjective counterarguments, mostly based on the cultural biases or the circumstances that are beyond influence or control of the humanity at the time, with no reason to believe that those are to change in the nearest future. Thus, the euthanasia-supporting policy provides an effective decision rather than subjective assumptions. First, it ends the pain and agony of the very ill person and his or her family members. Moreover, the paramedical workers and the material resources used to maintain the life of the terminally ill individual, who death is very certain, can be utilised for other patients who have illnesses that are curable. Furthermore, the family members of the patient experience economic hardships in terms of medical expenses and hence they are relieved. Final and probably the most important offer of the active voluntary euthanasia is an opportunity for independence and strength for the patients, who have a sound mind, to have control over their suffering and endurance.
Meanwhile keeping in mind the utilitarian approach shown in Mill’s theory, there is a substantial danger of crossing the line, and the need of sustaining the balance in the amount of the medical professionals’ rights and responsibilities, as well as refining and developing the due criteria, consistent with the circumstances and recently developed technologies and approaches. The data and the lessons for the further refinement of the euthanasia policies can be obtained from the evaluating pros and contras of the existing relatively efficient policies on the euthanasia, such as those represented by the Dutch 2011 Termination of Life on Request and Assisted Suicide Act.
Evaluation of the euthanasia policy in the Netherlands: Pros and contras
The experience of sustainable policy on euthanasia, physician-assisted suicide, and other ending-of-life medical procedures has been existing for a couple of decades. The thorough studies on this issue were made on the legislative and medical standpoints in 1990, 1995 (Onwuteaka-Philipsen et al. 2012). However, after the Termination of Life on Request and Assisted Suicide Act approved in 2001, there were significant changes in the attitudes of both medical sphere and the public’s eye towards the issue of euthanasia, its advantages, and disadvantages, the results of its acceptation and nuances of the current health policy on this issue. Hence, to evaluate the pros and contras of the current legislation regarding euthanasia and physician-assisted suicide, as well as ending-of-life without explicit request procedures, this paper is to explore the main standpoints of the 2001 Termination of Life on Request and Assisted Suicide (Review Procedures) Act, the context of its implementation in the Netherlands, and the difference between euthanasia, physician-assisted suicide, and ending-of-life without explicit request.
The review of the euthanasia policy in the Netherlands: quantitative data
The most obvious indicators of the dynamics and advancements of the euthanasia policy development in the Netherlands is the data accessible for over two decades. There are various studies aimed at collecting the data regarding cases of euthanasia and physician-assisted suicide (Onwuteaka-Philipsen et al. 2012), and the decision-making in euthanasia from the points of view of patients, relatives and treating physicians (Dees et al. 2012).
According to the studies of Onwuteaka-Philipsen et al. (2012, p. 909), there number of cases of life-ending decisions leading to the procedures, including euthanasia, assisted suicide, end of life without explicit patient’s request, intensified alleviation of the symptoms, and forgoing life-prolonging treatment, increased from 2361 cases in 1990 to more recent 2570 cases in 2005, and 3685 in 2010. The data can be interpreted as an indicator of rising awareness of the procedures, and growing public acceptance. However, it is important to bear in mind the fact that not all requests are granted by the physicians, and there are substantial nuances that differ the procedures of euthanasia from one another.
Also, compared to the number of all deaths in the Netherlands in the given years, the percentage of euthanasia cases increased from 4,8% in 2005 to 6,7 % in 2010 (Onwuteaka-Philipsen et al. 2012), as well as the percent rate of the requests from the patients that were granted, from 37% to 45%, on the other hand, the rates end-of-life procedures without explicit request decreased from 0,8 % to 0,2% of all death cases (Dees et al. 2012).
Among the most significant reasons to grant a request euthanasia that are declared by the medical professionals, most often in 2010 there were the wish of the patient (82% and 85% in 2005 and 2010 respectfully), no further expectation of the patient’s improvement (85% in 2005, 82% in 2010), lack of alternatives for treatment (73% in 2010), and loss of dignity because of the illness (increased from 60% to 61% over 5 years) (Onwuteaka-Philipsen et al. 2012). Thus, there are no crucial divergences between the qualitative data regarding the due reasons for medical euthanasia between 2005 and 2010. Such a sustainable rate indicates that there is no need, for now, to make changes to such aspect of the euthanasia policy as due reasons for granting the procedure since the data indicates no abuses or malfunctioning of the current regulations over the years.
Policy on euthanasia and physician-assisted suicide
Given the fact that not all patients’ requests are considered due by the physicians, it is important to consider cases that do not result in euthanasia and analyze the policy nuances defining the criteria for the patients, their families, and medical professionals.
There currently is no available data regarding the cases of the patients ending their life themselves because of the terminal illness or suffering caused by it. Such results would influence the policy-making aspects of the issue and presumably affect some regulations since there are also some reasons for those individuals to reject the legal alternative of euthanasia.
There are conditions for both the patient and physician to grant the procedure. First of all, it is their agreement on the issue that the patient’s suffering is unbearable, the second one, as it was previously noted, the ethical condition of the patient’s eligibility to request the procedure, the absence of the expected improvement or alternative options of the effective treatment, and the last of the main conditions is the necessity to consult the independent specialist, another qualified physician (Dees et al. 2012).
Such approach to the policy is aimed at minimizing the risks of the medical professional’s mistake, and guaranteeing the eligibility of the procedure. All cases of euthanasia and physician-assisted suicide are legally required to be reported. However, it is different for the cases of ending life procedures without explicit request by means of alleviation of the symptoms and, or forgoing life-prolonging treatment. Such types of procedures entail further investigation.
Policy on ending life without explicit request, alleviation of the symptoms and forgoing life-prolonging treatment procedures
The tendency is that there is slightly different legislation, and therefore, different policy, with the regard to the cases of euthanasia and assisted suicide and cases of ending of life without explicit request. The latter is sometimes legalised in the countries where euthanasia is considered illegal.
In the Netherlands, such procedures can be applied in the cases when the patients themselves are unable to communicate the explicit request, although the conditions for the procedure expressed in the Criminal Code and 2001 Termination of Life on Request and Assisted Suicide Act are met, with the emphasis on no options available for the effective treatment for the patient. In many of such cases, the applied procedure is considered the alleviation of the symptoms or forgoing life-prolonging treatment, which is legally not the same as euthanasia that presupposes the patient’s request. Therefore, the fact that those cases are not reported as euthanasia has nothing to do with the unwillingness to report euthanasia, and it is no reflection on the policy because there are significant nuances that differ euthanasia and assisted suicide from those procedures.
Lessons to learn from the euthanasia policy in the Netherlands
The studies in many European countries, including the Netherlands, the UK, Belgium, Switzerland, Italy, and Germany, suggest that the major difference between ending of life with the explicit request, and such procedure without the patient’s request (Dees et al. 2012). The differences concern mostly the circumstances in which the procedure is performed.
Hence, the experience of the euthanasia policy implemented in the Netherland is significant in a number of aspects. First, the procedures such as euthanasia and physician-assisted suicide are mostly associated with the patients at home, dying of the terminal diseases, and showing the explicit request for the procedure. Whereas, the alleviation of symptoms and related procedures that do not require an explicit request, and are legalised in many other countries, are mostly performed at the medical institutions.
Secondly, the implemented policy has cohesive and compliant regulations, which exclude the possibility of abuse or malfunctioning of the policy. And according to Onwuteaka-Philipsen et al. (2012, p. 912), the rate of recurrence of medical professionals ending the life of a patient “in the absence of an explicit request does not seem to be increased in countries where euthanasia is legalised”.
Furthermore, the policy is based on the ground of medical ethics and anticipates and includes many scenarios and situations, so that to provide an incurably ill individual with a reasonable human right to make a choice of how they are living and how they can end their life in a situation of unbearable pain and suffering.
The policy on euthanasia and physician-assisted suicide that is now functioning in the Netherlands has a number of advantages. The ethical, sociological, legal and criminological aspects of the procedure together form a compliant and inter-dependable structure of regulations. Among the highlight of the thought-through policy on voluntary euthanasia in the Netherlands is the attention to the circumstances of the each particular case, many studies, and researches that provide the feedback on the policy, and the detailed differentiation between the procedures reviewed in the 2001 Termination of Life on Request and Assisted Suicide Act. All these factors create a consistent policy that can be served as the example in the case of implementation in other countries.
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